Paraphilias

Presented by Dr Pavan Kumar K Chaired by Dr Manju Bhaskar

INTRODUCTION
• Greek words “para” - next to and “philia” - love. • “next to or along side of love” • normal sexual behavior results in healthy, nonharming, sexual contact. • Sexual practices that result in unhealthy, harming sexual contact are judged undesirable and in need of change. • Also behaviors considered evolutionarily maladaptive and uncommon. • Inability to resist an impulse for the deviant sexual acts.

Definition
• defined as recurrent and preferred sexually arousing fantasies or behaviors involving • nonhuman objects, • sadomasochistic behaviors, or • children or other non-consenting persons. • duration must be for at least 6 months and • must not be due to another disorder.

• identified paraphilias 1st in his 1886 Psychopathia Sexualis (Sexual Psychopathy). • Groundwork for the development of research and treatment. .study of sexology as a psychiatric phenomenon.History • Richard von Krafft-Ebing • a German psychiatrist .

• all paraphilias as infantile. . • individuals progress toward “normal” heterosexuality unless prevented.• Sigmund Freud • human sexuality advance through stages.e. not mature sexual behavior. i.

Comparative Nosology .

political.a mental disorder .“associated with present distress or disability or significantly increased risk of suffering death. disability. • DSM suggests that participation in paraphilic behavior is consistent with the diagnosis of paraphilia. pain. religious. • In other words paraphilic behavior is synonymous with the presence of a paraphilia. . or important loss of freedom.g.” • Neither deviant (e.Paraphilias – a mental disorder • DSM . or sexual) nor conflicts that are primarily b/w the individual and society are mental disorders • unless the deviance/conflict is a symptom of a dysfunction in individual.

. • DSM-IV-TR reclassified transvestism from a disorder of gender identity to a paraphilia called transvestic fetishism. and ego-dystonic homosexuality. psychosexual dysfunctions.• DSM classified sexual deviations with psychopathic personality disturbances .belief that sexual deviations were unlawful and thereby those individuals engaging in them were psychopathic. • DSM-III changed nomenclature from sexual deviation to paraphilia. • Paraphilias were classified as psychosexual disorders.sexual deviations . • DSM-II -. which included gender identify disorders.classified with PDs.

• pornography dependence .. • protracted heterosexual (nymphomania. • telephone-sex dependence and • severe sexual desire incompatibility .paraphilia-related disorders • Sexual impulsivity disorders (SIDs) • Paraphilias • Paraphilia-related disorders • sexual behaviors affected are not considered “deviant” with respect to contemporary cultural norms • compulsive masturbation.) or homosexual promiscuity.

Epidemiology • data regarding paraphilic phenomena are limited due to the ego-syntonic nature of these recurrent erotic interests • Gender Ratio • Paraphilias are predominantly male sexuality disorders. . autoerotic asphyxia the paraphilias are almost never diagnosed in females. • Except for sadism and masochism. although some cases have been reported.

7 33 sex with an animal young boy in sexuality .Prevalence in Nonparaphilic Populations • difficult to obtain • In one study of General population fantasies 5.7 young girl in sexuality raping adult women masochistic 61.2 11.3 3.

.• A study of college students' sexual behavior voyeurism frottage 42 making obscene telephone calls coercive sexual activity sexual contact with girls under age 12 exhibitionism 2 5 3 8 35 • A total of 65% reported having participated in some variant of paraphilic behavior.

Paraphilic population • Data gathered from more than 90 treatment programs throughout North America regarding 2.8 20.1 voyeurism exhibitionism 13.2 fetishism frottage 13.3 .7 11.2 37.129 cases of individuals seeking assessment paraphilic population child molestation 10.

• between female and male victims. • between family and nonfamily members. individuals with paraphilia thought to be obsessed with one type of paraphilic behavior.cross over • Initially. and pedophilia) and nontouching (voyeurism and exhibitionism) of their victims. and • to victims of various ages . • Recent studies suggest that individuals with paraphilias “cross over” from one paraphilia behavior to another • between touching (frottage. rape.

. • Bancroft (1989) proposed that paraphilias may develop in response to individual differences in the nervous system and • the same conditions that allow the development of one paraphilia may invite the development of others.• Lehne and Money (2003) proposed the term multiplex paraphilia to describe variations of paraphilic content being expressed in one individual.

Classification • The paraphilic fantasy or behavior may be obligatory (required for arousal) or nonobligatory (wherein the individual experiences arousal with other erotic stimuli as well). • Many individuals report a nonobligatory paraphilic pattern in early life. with the pattern becoming increasingly obligatory over time and with increased exposure to the stimulus .

masochism. and transvestic fetishism. paraphilias can be partitioned into two types: • coercive and noncoercive. frotteurism. for which patients may be apprehended by legal authorities for imposition of their paraphilic drives onto others. • Noncoercive paraphilias are more likely to consist of solo and/or consensual activities. • Coercive paraphilias. • these include sadism. fetishism. • consist of nonconsensual activities such as voyeurism. exhibitionism. and pedophilia. .Classification • For assessment and treatment purposes.

Etiology • Unknown • Biological theory • structural impairment of brain regions critical for sexual development • Subtle defects of the right amygdala and closely related structures .pathogenesis of pedophilia and might reflect developmental disturbances or environmental insults at critical periods .

.• Neurological hypothesis – • sexual deviance is associated with frontal and/or temporal lobe damage. • This damage may translate into an individual's inability to control sexual impulse or directly cause paraphilic behavior .

appetite. • 3rd . .sexual effects of pharmacological agents that affect monoamine NTs can have both significant facilitative and inhibitory effects on sexual behavior. • 2nd .monoamine NTs.NE & 5-HT .Kafka) • 1st . • 4th . and consummatory behavior.drugs that enhance central 5HT function reported to ameliorate paraphilic sexual arousal and behavior.paraphilic disorders have Axis I comorbidy with nonsexual psychopathologies associated with monoaminergic dysregulation.• Monoamine hypothesis (1997.modulatory role in human sexual motivation. DA.

resulting in a repetitive pattern of sexual behavior that is not mature. • So an individual repeats or reverts to a sexual habit arising early in life.Psychoanalytical Theory • represent a regression to or a fixation at an earlier level of psychosexual development. .

• Indeed. • The persistent. a history of childhood sexual abuse is sometimes seen in individuals with paraphilias.• Another theory holds that these are all expressions of hostility in which sexual fantasies or unusual sexual acts become a means of obtaining revenge for a childhood trauma. repetitive nature of the paraphilia is caused by an inability to erase the underlying trauma completely. .

• there must usually be some predisposing factor. . such as difficulty forming person-to-person sexual relationships or poor self-esteem. • Nonsexual objects can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity. • not usually a matter of conditioning alone.Behaviorist Theory • paraphilia begins via a process of conditioning.

• situations or causes that might lead in a paraphiliac direction: • parents who humiliate and punish a small boy for strutting around with an erect penis. • fear of sexual performance or intimacy. • inadequate counseling. . • psychosexual trauma. • excessive alcohol intake. • physiological problems. • a young boy who is sexually abused. • sociocultural factors. • an individual who is dressed in a woman's clothes as a form of parental punishment.

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82 Voyeurism 302.89 Frotteurism 302.4 Exhibitionism 302.2 Pedophilia Specify if Sexually Attracted to Males/ Females / Both Specify if: limited to Incest Speciify type: Exclusive Type/ Nonexclusivc Type 302.81 Fetishism 302.8 Other disorders of sexual preference F65.2 Exhibitionism F65.5 Sadomasochism F65.9 Paraphilia NOS .1 Fetishistic transvestism F65.6 Multiple disorders of sexual preference F65.84 Sexual Sadism 302.3 Voyeurism F65.0 Fetishism F65.83 Sexual Masochism 302.Diagnosis • • • • • • • • • • • • • ICD 10 F65 Disorders of sexual preference Includes: paraphilias Excludes: problems associated with sexual orientation (F66.3 Transvestic Fetishism specify if: With Gender Dysphoria 302.9 Disorder of sexual preference. unspecified • • • • • • • • • • • • • • • DSM IV Paraphilias 302.-) F65.4 Paedophilia F65.

• G2. Recurrent intense sexual urges and fantasies involving unusual objects or activities. The preference has been present for at least six months. • G3. . Acts on the urges or is markedly distressed by them.F65 DISORDERS OF SEXUAL PREFERENCE – ICD 10 DCR • G1.

amount to a disorder when so compelling & unacceptable as to interfere with sexual intercourse and cause the individual distress A. The fetish objects are not limited to articles of female clothing used in cross-dressing (as in Transvestic Fetishism) or devices designed for tactile genital stimulation ( a vibrator). cause clinically significant distress or impairment in social. The general criteria must be met. female undergarments) B.81 Fetishism diagnosed only if the fetish is the most important source of sexual stimulation or essential for satisfactory sexual response. recurrent..0 Fetishism F65. or other important areas of functioning. .0 Fetishism 302. occupational. Fetishistic fantasies are common. The fetish (some nonliving object) is the most important source of sexual stimulation. B.F65. A. C. Over a period of at least 6m.g. urges. or is essential for satisfactory sexual response. intense sexually arousing fantasies. or behaviors involving the use of nonliving objects (e.

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F65. Over a period of at least 6m.3 Transvestic Fetishism A. or other important areas of functioning. B. The wearing of clothes of the opposite sex principally to obtain sexual excitement. or behaviors involving crossdressing. The wearing of articles or clothing of the opposite set in order to create the appearance and feeling of being a member of the opposite sex. there is a strong desire to remove the clothing. recurrent.1 Fetishistic transvestism Includes: transvestic fetishism. B.1 Fetishistic transvestism A. The cross-dressing is closely associated with sexual arousal. in a heterosexual male. Once orgasm occurs and sexual arousal declines. Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity . cause clinically significant distress or impairment in social. intense sexually arousing fantasies. occupational. F65. 302. C. The general criteria for must be met. urges.

. • Usually more than one article is worn and often a complete outfit. plus wig and makeup. but worn also to create the appearance of a person of the opposite sex.Fetishistic transvestism • distinguished from simple fetishism in that the fetishistic articles of clothing are not only worn.

• A history of fetishistic transvestism is commonly reported as an earlier phase by transsexuals and probably represents a stage in the development of transsexualism in such cases. .Fetishistic transvestism • distinguished from transsexual transvestism (Crossdressing) • by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines.

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F65.2 Exhibitionism almost limited to heterosexual males who expose from a safe distance in some public place. For some, it is the only sexual outlet, but others continue the habit along with an active sex life with long-standing relationships. more pressing at times of emotional stress or crises. Most find difficult to control and ego-alien. If the witness appear shocked, frightened, or impressed, the exhibitionist's excitement is often heightened.

F65.2 Exhibitionism A. The general criteria must be met. B. Either a recurrent or a persistent tendency to expose one's genitalia to unsuspecting strangers (usually of the opposite sex), almost invariably associated with sexual arousal and masturbation. C. There is no intention or invitation to sexual intercourse with the "witness(es)“.

302.4 Exhibitionism A. Over a period of at least 6m, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the exposure of one's genitals to an unsuspecting stranger. B. cause marked distress or interpersonal difficulty.

F65.3 Voyeurism A recurrent or persistent tendency to look at people engaging in sexual or intimate behaviour such as undressing. This usually leads to sexual excitement and masturbation and is carried out without the observed people being aware.

F65.3 Voyeurism A. The general criteria must be met. B. Either a recurrent or a persistent tendency to look at people engaging in sexual or intimate behaviour such as undressing, associated with sexual excitement and masturbation. C. There is no intention to reveal one's presence. D. There is no intention to have a sexual involvement with the person(s) observed.

302.82 Voyeurism (peeping) A. Over a period of at least 6m, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. B. Cause marked distress or interpersonal difficulty.

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302. recurrent. usually of prepubertal or early pubertal age. Sexually Attracted to Males Sexually Attracted to Females Sexually Attracted t o Both Specify if: Limited to Incest Specify type: Exclusive Type (attracted only to children) Nonexclusive Type . C.4 Paedophilia A sexual preference for children. A persistent or a predominant preference for sexual activity with a prepubescent child or children. B. Some paedophiles are attracted only to girls. intense sexually arousing fantasies. B. The person is at least age 16 years and at least 5 yrs older than the child or children in Criterion A. Specify if.2 Pedophilia A. or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger). F65. The general criteria must be met. Rarely identified in women.4 Paedophilia A. The person is at least 16 years old and at least five years older than the child or children in B. Over a period of at least 6m.F65. and others again are interested in both sexes. C. urges. others only to boys. Cause marked distress or interpersonal difficulty.

are men who retain a preference for adult sex partners but. . especially if the participants are of the same sex. habitually turn to children as substitutes. because they are chronically frustrated in achieving appropriate contacts.• Contacts between adults and sexually mature adolescents are socially disapproved. especially if the perpetrator is himself an adolescent. but are not necessarily associated with paedophilia. • Included among paedophiles. • An isolated incident. • Men who sexually molest their own prepubertal children occasionally approach other children as well. however. but in either case their behaviour is indicative of paedophilia. does not establish the presence of the persistent or predominant tendency required for the diagnosis.

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83 Sexual Masochism 302. beaten. 302. If the individual prefers to be the recipient of such stimulation . bound. or behaviors involving acts (real. Over a period of at least 6m. either as recipient (masochism). intense sexually arousing fantasies. not simulated) of being humiliated. Mild degrees of sadomasochistic stimulation are common to enhance otherwise normal sexual activity. which involves at least one of the following: (1) pain. The sado-masochistic activity is the most important source of stimulation or necessary for sexual gratification. (2) humiliation. urges. recurrent. F65. if the provider-sadism. C. or the sexual urges or fantasies cause marked distress or interpersonal difficulty. B. The general criteria must be met. or as provider (sadism). Over a period of at least 6m. B. or behaviors involving the act (real. Often an individual obtains sexual excitement from both sadistic & masochistic activities. A preference for sexual activity. or otherwise made to suffer.84 Sexual Sadism Sexual Masochism A. recurrent. or both. .5 Sadomasochism A preference for sexual activity that involves bondage or the infliction of pain or humiliation. intense sexually arousing fantasies. Sexual Sadism A.masochism. (3) bondage.F65. This category should be used only if sadomasochistic activity is the most imp source of sexual gratification. The person has acted on these sexual urges with a nonconsenting person. not simulated) in which psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.5 Sado-masochism A. urges.

.• Sexual sadism is sometimes difficult to distinguish from cruelty in sexual situations or anger unrelated to eroticism. • Where violence is necessary for erotic arousal. the diagnosis can be clearly established.

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.F65. transvestism.6 Multiple disorders of DSM IV sexual preference sexual preference Sometimes more than one disorder of sexual preference occurs in one person and none has clear precedence. should be listed.6 Multiple disorders of F65. The likelihood of more No similar entity than one abnormal sexual preference occurring in one individual is greater than would be expected by chance. and sadomasochism. For research purposes the different types of preference. The most common combination is fetishism. and their relative importance to the individual.

zoophilia (animals).F65. Necrophilia should also be coded here. smearing faeces. and urophilia (urine). when they take the place of ordinary sexual contacts. Masturbatory rituals of various kinds are common. but the more extreme practices. but are not limited to. telephone scatologia (obscene phone call s). making obscene telephone calls. rubbing up against people for sexual stimulation in crowded public places (frotteurism). partialism (exclusive focus on part of body). relatively uncommon. or piercing foreskin or nipples may be part of the behavioural repertoire in sadomasochism. Swallowing urine. amounts to abnormalities . Examples include.8 Other disorders of sexual preference ICD 10 ICD10 DCR 302. use of strangulation or anoxia for intensifying sexual excitement. necro philia (corpses ). such as the insertion of objects into the rectum or penile urethra.9 Paraphilia NOS Paraphilias that do not meet the criteria for any of the specific categories. or partial self strangulation. kusmaphilia (enemas). sexual activity with animals. coprophilia (feces). and a preference for partners with some particular anatomical abnormality such as an amputated limb.

unspecified • Includes: sexual deviation NOS .9 Disorder of sexual preference.• F65.

• The test is conducted by placing a small circular spring gauge around the penis.phallometric assessment of physiological sexual arousal by measuring penile circumference in males. . • This gauge is calibrated to measure changes in the circumference of the penis in response to both audio and visual stimuli depicting various sexual vignettes.Pathology and Laboratory Examination • Plethysmography .

the erect penis displaces the gauge and a measurement is recorded. phallometric testing is helpful in determination of an individual's response to treatment. .• As the individual becomes aroused with the stimuli. • In addition to diagnostic evaluations.

• If the molester reports h/o learning difficulties consistent with MR & explains his molesting behavior on his desire to “have sex with anyone. • If the molester describes sexual urges and fantasies to sexual contact with a prepubescent individual. PD. • For ex. . they meet the criteria for pedophilia. • In order to determine what diagnosis fits the child molester one has to understand what motivated the molester to have sexual contact with the child.Differential Diagnosis • make a diagnosis based on an individual's behavior rather than on the individual's sexual preference. MR. or substance abuse. the DD for a child molester may include pedophilia.” the diagnosis is MR & possibly PD.

• Patients may participate in such behaviors by virtue of intellectual limitations. and impulse control disorders.comorbidity • • • • • • • nonparaphilic Axis I comorbidities in paraphilic patients. borderline intellectual functioning or MR. retrospectively diagnosed childhood ADHD. stimulus availability. Axis II conditions. and the most prevalent was ASPD. may play a role in paraphilic-type behaviors. although patients technically are not paraphilic. or lack of SST or sex education • In one study of 47 incarcerated sexual offenders. substance use disorders. . anxiety disorders. 72% had at least one PD. mood disorders.

• Although it has been shown that individuals may cross over from one paraphilia to another.Course and Prognosis • Paraphilic behaviors emerge in adolescence and early adulthood. . • In general paraphilic behaviors are chronic. they are often difficult to treat. • Because of the early onset and repudiated biological priming of the paraphilias. the overall course of paraphilic behavior is chronic.

Treatment Background • Empirical evidence for treatment of individuals with paraphilias is derived from studies of sex offenders .

Assessment Tools • no reliable or valid psychometric inventories • Derogatis Sexual Functioning Inventory and the Psychopathy Checklist—Revised (Derogatis 2008) .

.Biological Treatment • The scientific basis of biological treatment in paraphiliacs is the reduction of sexual behaviors by decreasing testosterone levels.

The castrated individuals recidivated at a rate of 4. • The neurosurgical procedure . • significant adverse effects and considered largely ineffective. • Sturup followed 107 castrated sex offenders and compared them to 58 who were not castrated for 18 years.Surgical Treatment for sexual offenders • Neurosurgery and castration. • Surgical castration is the removal of the testes and globally reduce available androgen.stereotaxic removal of parts of the hypothalamus to disrupt production of male hormones and decrease sexual arousal and impulsive behaviors.3 % and the uncastrated individuals recidivated at a 43 % rate .

.. • Some states in the US (Texas. California) mandate chemical or surgical treatment of dangerous sexual offenders. as chemical castration achieves the same results and spares the procedure. • The effects of surgical castration achieved through chemical castration (i.Chemical castration • antiandrogen and hormonal medications rendered surgical castration nearly obsolete. the use of medications to decrease testosterone production). without the invasiveness and irreversibility of surgery.e. • Controversy exists as to whether surgical castration should be offered as a treatment.

erections. hot and cold flashes. • little known abt long-term sequelae of antiandrogen treatment. .weight gain. • Cyproterone acetate (CPA) and medroxyprogesterone (MPA) MC antiandrogens used to reduce serum level of testosterone.Antiandrogens • block production / interfere with action of male hormones. and feminization. hypertension. phlebitis. • s/e . muscle cramps. ejaculations & spermatogenesis. hyperglycemia. • A meta-analysis of antiandrogen studies (Grossman et al) suggest that recidivism rates as low as 1 % for treated patients and as high as 68 % for untreated patients.I complaints. G. • Thus reducing libido. liver dysfunction.Pharmacologic Treatment.

• Inhibit secretion of LH & decrease plasma testosterone levels • Produce chemical castration in that the hypothalamic–pituitary axis is exhausted & potent inhibition of gonadotropin. few s/e. None of the treated patients had a relapse. weight gain. and insomnia. MPA. • s/e . or SSRIs reported better effects when taking LHRH agonists.Hormonal Agents • Leuprolide & triptorelin . hypertension.erectile/ejaculatory problems and gynecomastia.decreased bone mineral density or osteopenia. hyperglycemia. • MC s/e .hormonal agents referred as longacting GnRH agonists. better tolerated alternatives to antiandrogens . • Effective. diabetes. • Patients previously treated with CPA.

. fluvoxamine. • Though SSRIs are effective.Selective Serotonin Reuptake Inhibitors (SSRIs) • mechanism poorly understood • effective in reducing paraphilic symptoms. and fluoxetine were equally effective in reducing paraphilic symptoms. presently insufficient data to conclude that SSRIs are equally efficacious as antiandrogens or hormonal agents. • Greenberg and colleagues demonstrated that sertraline .

Cognitive-Behavioral Therapy • mainstay of treatment for patients with paraphilia (Safer Society Foundation and ATSA) in reducing recidivism • CBT focuses on the interaction of thoughts. • identifying and challenging cognitive distortions and breaking through patients’ denial. • Thought substitution. and distractions are taught as ways to replace maladaptive thoughts and redirect thinking toward more healthy topics. which is particularly important for patients with coercive paraphilias . and behaviors. affects. redirection. • victim empathy training.

and developing a plan of action if faced with a trigger are imperative for this patient population. and positive conditioning • Relapse Prevention • Similar to patients who abuse substances • Identifying risks. behavioral abstinence. covert sensitization. aversive stimulation • Other methods include behavioral rehearsal. learning to deal with urges. fading.• behavioral methods.satiation. .

sex drive reducing drug therapy were the least acceptable forms of treatment. and relapse prevention are integral components of a treatment program. castration. SST & group therapy. • Recent research reveals victim empathy.1994) identified • >90% of programs utilized victim empathy. remorse. • A survey (Safer Society. anger management &cognitive distortions.Models of Treatment • Cognitive behavior group treatment & pharmacologic treatment. • 75% provided social skills/assertiveness training. . • 42% prescribed SSRIs. responsibility training. and 19% prescribed antiandrogens. • Research revealed the preferred therapies were individual psychotherapy.whereas • aversion conditioning.

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. • As such the traditional codes of ethics employed in medical treatment are not applicable to the treatment of sex offenders. court-ordered sex offender treatment is not voluntary. • Obviously.Ethical and Legal Considerations • unique to this population. • A condition of informed consent for medical treatment is that the consent must be voluntary. • A significant percentage of sex offenders receiving treatment have been mandated by the courts to do so as part of sentences of incarceration or release into the community. • The concept of mandated or involuntary treatment raises the issue of whether informed consent is possible in sex offender treatment.

and as such the court becomes the decision maker regarding treatment.• Individuals who reject treatment are subject to punishment imposed by the courts. patients have a right to refuse various types of treatment. The court views sex offenders as incompetent patients. in order to gain community release or avoid imprisonment. . The right to refuse treatment is based on an individual's constitutional right to privacy. • In the medical model. • Sex offenders are required to complete particular programs. • Individuals who have been court ordered to receive treatment do not have a choice regarding the type of treatment or the treatment provider. irrespective of any other treatment they might be receiving.

past and potential victims. ethical and practice guidelines developed by the Association for the Treatment of Sexual Abusers (ATSA). correctional officers. .physician's obligation to keep information learned in a professional relationship private from others.patient's right to prevent a physician from providing testimony about personal medical information.Confidentiality and Privilege • Confidentiality . members of their family. they are required to give permission for their cases to be discussed with both clinical & nonclinical personnel. and those associated with them and fellow offenders. • Both are routinely breached in sex offender treatment. • Privilege . • When individuals enter treatment. • In response to the deviations from traditional ethical codes inherent in sex offender treatment.

admission of guilt. . they represent a public commitment to clients and society toward the goal of preventing sexual violence. that is.ATSA's code of ethics • endorses standards of professional conduct that promote competent practice. • ethical care of sex offenders is achieved by encouraging individuals to take responsibility for their behavior. • maintains that the identification and collaborative management of risk and safety factors are indeed in the best interests of both sex offender patients and potential victims due to the grave consequences incurred by sexual offender recidivism. and as such.

• sex offender is used to refer to an individual who has been legally convicted of a sex offense. .Legal Issues • Clinicians should remain mindful that “paraphilic patients” are not necessarily “sex offenders”.

as a fact or expert witness). or • as provider of a second opinion. this may limit his or her honesty or disclosure to the clinician . the clinician needs to understand • his or her role—as a clinician treating the patient. • If the patient was forced into the evaluation because of legal difficulties. • as a witness in court (for either the prosecution or the defense.• When evaluating a patient as part of legal or criminal proceedings.

• Findings on forensic populations may not generalize to nonforensic patient populations. • Specific populations may be quite different from general paraphilic populations. such as ASPD. . may not represent paraphilias per se. • Other aspects of demographics & epidemiology-not well defined. sexually deviant or opportunistic behaviors as related to PDs.Key points • Paraphilias are predominant in males. • Difficulties arise in evaluation and diagnosis because patients hesitate to get treatment (egosyntonic nature). • Also.

• The clinician determines why the patient presented at the current time and whether the individual truly desires treatment. sex education. . and vocational rehabilitation.• Treatment begins with a thorough assessment of the patient. • Evaluation and treatment of psychiatric comorbidities is essential. • Comorbid issues. • Relapse prevention techniques may be relevant as well. may be secondary to paraphilic behaviors or stresses (interpersonal problems. such as SST. such as mood or anxiety disorders. • Cognitive-behavioral therapy is the mainstay of psychotherapy • Other behavioral therapies. also may be helpful for specific patients. threat of discovery).

antiepileptics. anxiolytics. • Routine follow-up appointments and monitoring of side effects is crucial with any medication. • Hormonal agents may act by decreasing testosterone. psychostimulants. desire. • Antipsychotics. • Selective serotonin reuptake inhibitors are most widely used. .• Psychotropics -commonly used in this patient population. and the opiate antagonist naltrexone may prove beneficial as well. and arousal response.

• Current psychiatric literature concerns the sexual offender population. . formalized research. and treat paraphilias is among the least evidence-based undertakings in all of psychiatric practice today. and well-reasoned therapeutic trials. • This patient population requires future research. for conceptualizing the most appropriate treatment modalities for this population in need of care.CONCLUSION • To assess. which is not necessarily synonymous with the paraphilic population in general. via intensive investigation. manage.

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